23838 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT.PEN ONLY
Bulidin Pm'cat Identification - - - PERMIT NO.23838
Building Address:
Clv�
wns Q °� L DAM
CITY OF CUPERTINOBUILDING DIVISION �APPUCAA
/ �K9Z
c ract sore: le. o: .APPLICATION 1 PERMIT
Architat/EnBUILDINGELECTRICAlPLUMBINGMECHAMCAL CATEGORY CONTROLN
gi lir Llc.Na:
QrY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affbmthatI am licensed under provisions of Chapter 9(comment, APPUANCESRESIDENTIAL JOB DESCRIPTION
It...1 Section 70W)old offeon3otlhe BuslmssandProfesslonaCade,end my
licensetsedion( ddsio PANELS [r]N)LZ
se load Lie.#
Dat Contracto /XTIM TO 2DOAMPS ,
ARCHITECTSDECLA ION 201-I0W AMPS
QO I understand my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/sQ.FT.
X Licensed Professional - SIGNSELECTRICAL
�+C N - OWNER-BUILDER DECLARATION + /.�' w p p i
L"�
ti Ihereby atflranthatlass exempt(romthe ConlractohLicenae SPECIAL CIRCUIT/MISC L law forth¢ _ «r' d�I
o following reason.(Section 7m1.5,Business and Professions Code:An ti r I i
F � countywhich requires a perret to construct,alter,Improve,demollsh,orrepalr TEMP. OR POLE]NST. 1; i,1,`i I,.� •� II ij d
.o a nystm=mpdortoiUts ance,alsomqure.theapp8antforsuchperMtto ppyyBg DEVICES �1 (�J Il
r file a signed statement that he is licensed pursuant to the provisions of the / I•
O w Contractors ti
License law(Chapter 9(commenting with Section 7000)of Divi- L [ L ATIO
I n3ofthe Buatnema dProfembmCode)orlhathelsexempttherefromand SWIMMING POOL ELECTRIC J
yy�' the basis for the alleged exemption. Any violation of Section 70312 by any
p�
applicant fora permit subjects the applicant to a civil penalty a not more than OUTLETSSWITCHES-FIXTURES
lie five hundred dollars($500). NEWRESIDENTIALELECTR
.-•�n ❑I,as owner of the property,or my employees with wages as their sole SQ.Fr. STORIES TYPE CONSTRUCTION
mpeasation,wBf dothe work,and thestmcture is not intended or offered for
sale(Sec.7044,Business and Professions Cade:The Contractor's License Law
$ does not apply to an owner of property who builds or improves thereon,and
a who does such work himself orthrough his own employees,provided that such — OCC.GROUP RES.UNITS
Improvements are not Intended oroffered forsals.If,however,thebuilding or TOTAL:
Improvement tsaold within one yearof complelion,the owner-bullderw111 have
tf'ekurden of proving that he did not Wild or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7614,Business and Professions Code: `
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VFM-WATER ffA)
build.or improves,thereon, and who contracts for such pRojects with a FEE SUMMARY
,,11LLt.��actor(.)licensed pursuant to the Contrachus License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y .N
. Owner Date AILEIT p
�s,,,....JJ WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOL TAX Y_ N_
Qpi hereby affirm that I have a certificate of consent to spytheure,ora RECEIPT N
cenhhirate o(Worken CDmpenaaHoninsurance oracertl(kd copythereo((Sec. GAS EA.SYS EM.1 INCAOUTLEI'S PARK FEE Y N
3BW,LbC. Aly��a RECEIPTN
On f 1 GAS EA.SYSTEM-OVER 4'(EA)
On HULLOING DIVISION FEES ' '
V-rtlBed copy fs hereby th the cid. GREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECK FEE
etified copy b filed with the city Inspection division.
CERTIFICATE OF UMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date Recei t#
'IThlseeNon need not be completed i(the permit tslor one hundred dollars
($1 W)orfyth WATER HFATER W/VENT/ELECTR ENERGYFEE Y N
]certify thatmthey person
of mannakso as toohich co permitisthe
I shall not employ any person In any mannerao an to become subject to the
WorompensaHon law.of Call(omla.Date WATER SYSTEM/TREATING PAID
Z Applicant NEW RESIDENTIAL ELMS. SQ.FT. Date Recel t#
Z O NO]TCE TO APPLICANT:],after making this Certificate of Exemption,you
Hshould become subject to the Worker Compensation provisions of the Labor TOTAL:
CN Code,you must forthwith comply with such provisions or this permit shall be
LU > deemed revoked. BUILDING 'E
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G Ihereby affirm that there is a conslrudion lending agency for the perform- ELECTRIC FEE
Q
7 Z unroof the work for whlchthts permit is issued&c.3097,Civ.C.) - TOTAL: PLUMBING FEE
U Lend.r'.Name -
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl havereadthls applicalionand statethatthe above information
6 Is correct.l agree to comply with all city and county orcluum eeeTatate laws PFRMITISSUANCE FEES PAID:
W relating tobulldingconstmctlon,and hmebyauthorize representatives ofthis
F— Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu pertlno Date Receipt#
U against liabilities,I.dgments,cami.nd expenses which may In any way... AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL'
gat t Id Cityincone ienceoft ¢gra rtl tgofthis permit.
1 Q , t �'ll 1�I1Data
d-3 �- p� AIR HANDLING R)NIT roVERfB,ab°CFM) CONSTRUCTION TAX
�Ig��of Appucent/CDatracmr DatAppeli]cimt/C�DatraVctuorr Date CJ EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
S HAZARDOUSMAI ALSDISC E
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 1W,000 BTU,
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Reeei t#
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BM TOTA
❑ Yen No -
Wllltheappifontor Nre building occupant use equipment or devices VENTILATION FAN(EINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHP OR 100,000 BTU)
4E'7 Yes n❑No pp�� pp
haveread Healthzard fety us Code,Se require25505, 5533undernd 25534 6.95 of BOLE&CAMP(OVER 700,000B f P9.'
the understand
Health he building
Code, otcurre2.5$05,25533and25534.I
understand thatn notify
the occupces not arrentlyhave
nts which
that it nort NEW RESIDENTIAL MEIN. SQ.FT.respp' a
priortsibilityisma to csufaytheoccteofO Rherequlrementswhichmust6emel Jium 25
prior to issuance ofaCertiticete of Ocwpanry. (�7 i
_ rU r
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE COPY